Physical Activity and MS: You Can Do It!

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2 Physical Activity and MS: You Can Do It! Sabine Koszegi, PT Manjit Bumrah, PT Toronto Rehab-University Health Network MS Society Presentation October 11, 2018

3 Acknowledgements We wish to thank Jo-Anne Howe, PT and Vivien Poon, PT for their contributions to this presentation.

4 Objectives Discuss the importance of exercise for people with Multiple Sclerosis Review types of exercise and commonly used exercise terms Review common barriers to exercise and strategies to overcome these barriers Discuss the role of physiotherapy in Multiple Sclerosis management

5 Take Home Message Participation in exercise and physical activity is an important part of managing MS When planning for exercise/physical activity consider selecting activities that are: Safe- from medical standpoint Safe- to reduce risk of injury 'Do-able'- individualized, right for your level of ability Don t forget to have fun! The information presented today is not intended to replace any advice received from your health care provider nor is it intended to be taken as specific healthcare advice. Rather, this information is intended as general information about exercise.

6 True or False? Exercise will increase your fatigue

7 True or False? Exercising can increase the risk of an exacerbation.

8 True or False? It is unsafe for individuals with MS to exercise because of the risk of overheating.

9 True or False? In order to get the benefits of exercise, you need to engage in continuous physical activity for a minimum of 30 minutes daily.

10 So why exercise?

11 Benefits of Exercise 1. maximize function/mobility 2. maintain flexibility/range of motion 5. decrease cardiovascular risk factors 6. improve mood 3. decrease fatigue/increase energy 4. increase strength and balance 7. improve sleep 8. increase quality of life Flachenecker,et al.(2002), Dalgas et al. (2009), Guner et al. (2015), Latimer-Cheung et al. (2013), Motl et al. (2012), Pilutti et al.(2014)

12 Effect of Exercise on the Nervous System Neuroplasticity: the capacity of the nervous system to change and reorganize itself Exercise can impact neuroplasticity in MS Kim et al. (2017), Wens et al. (2016)

13 Consequences of Inactivity: The Deconditioning Cycle Primary Impairments: Weakness, slowness of movement, altered muscle tone and posture, fatigue, decreased coordination and balance 13

14 What is Exercise? Physical activity: any movement that is carried out by the body that requires energy. Exercise: planned, structured, repetitive and intentional movement intended to improve or maintain physical fitness. Exercise is a subcategory of physical activity. Caspersen et al. (1985)

15 Types of Exercise Aerobic exercise Muscle strength Flexibility Balance

16 Aerobic Fitness and Exercise Aerobic fitness: The ability of your heart and lungs to supply working muscles with fuel during physical activity. The better your aerobic fitness, the more efficiently you can use oxygen, the longer you can go throughout your day Examples of aerobic exercise: Continuous brisk walking Pedaling on recumbent stepper Continuous swimming Cycling on stationary bicycle Cycling using an arm cycle Research evidence shows that doing aerobic exercise can improve aerobic capacity and fitness in people with MS Petajan et al. (1996), Mostert et al. (2002), Caspersen et al. (1985)

17 Aerobic exercise Types of Exercise Muscle strength Flexibility Balance

18 Muscle Strengthening Exercises Muscle strength: The amount of external force a muscle can exert. Muscle endurance: The ability of muscle groups to exert an external force for many repetitions or successive exertions Examples of equipment used for strengthening: Free weights Weight machines Resistance bands Body weight The terms sets and reps (repetitions) are used to measure how much strengthening exercise one has done Caspersen et al. (1985)

19 Aerobic exercise Types of Exercise Muscle strength Flexibility Balance

20 Flexibility Flexibility: the range of motion available at a joint Spasticity: an involuntary tightening of specific muscles, either experienced as spasms or constant tightening Stretching exercises help to maintain or improve range of motion may help with temporary relief of spasticity symptoms Caspersen et al. (1985), Halabchi et al. (2017) Caspersen et al. (1985)

21 Aerobic exercise Types of Exercise Muscle strength Flexibility Balance

22 Balance Balance: the maintenance of equilibrium while stationary or moving Why are balance exercises important? To improve stability and ability to stay upright To help to reduce risk of falls Examples of exercises that can challenge the balance system: certain yoga poses tai chi certain dance steps Caspersen et al. (1985)

23 Alternatives to Traditional Aquatic exercises Exercise Yoga Tai Chi Pilates

24 The FITT Principle FITT principle Frequency Intensity Heart Rate Talk Test Rate of Perceived Exertion Type Time

25 Modified Borg Rate of Perceived Exertion Scale 0 Nothing at All 1 Very Light 2 Light 3 Moderate* 4 Somewhat Hard** 5 Hard 6 Harder 7 Very Hard 8 Very, Very Hard 9 Very, Very, Very Hard 10 Maximal *3 Moderate Comfortable but slightly elevated breathing. You should be able to talk during the activity. **4 Somewhat Hard Exercising briskly. Aware breathing is deeper and slight feeling of fatigue. Adapted from emoecp/exertion.html

26 True or False? Exercise will increase your fatigue

27 Both - -True AND False Some fatigue is normal during exercise but it should not last longer than minutes after you stop BUT regular exercise has been shown to increase energy levels in individuals with MS.

28 True or False? Exercising can increase the risk of an exacerbation.

29 False Experts agree that currently there is no scientific evidence that exercise will result in an exacerbation or worsening of the disease To the contrary, there are numerous benefits!

30 True or False? It is unsafe for individuals with MS to exercise because of the risk of overheating.

31 False It is not unsafe but exercise does increase the body s core temperature For some, this makes nerve transmission more difficult and can temporarily make symptoms worse This is a transient increase in symptoms, (which subside with cooling off) and is NOT an exacerbation

32 True or False? In order to get the benefits of exercise, you need to engage in continuous physical activity for a minimum of 30 minutes daily.

33 False The Canadian Physical Activity Guidelines for Adults with MS recommends 30 minutes of moderate intensity aerobic activity, 2x per week strength training for major muscle groups, 2x per week & BUT... For those who are inactive, a lesser dose of exercise which is gradually increased will bring benefits DO WHAT YOU CAN!!

34 Some Common Barriers to Exercise Knowledge of how/where to exercise Fatigue Fear of an adverse event (exacerbation/ overheating) Increased tone Fear of falling Lack of motivation Transportation and cost

35 Tips to Help Manage Fatigue during Exercise Maintain a moderate exercise intensity (RPE scale) Avoid exercising to point of exhaustion Listen to your body and take rests as needed If fatigue after exercise is prolonged (more than min), adjust your program, (i.e. decrease reps/sets, time, intensity)

36 Tips to Help Avoid Overheating during Exercise Choose a cool place and time to exercise Hydrate before, during and after exercise Wear breathable, loose clothing Consider using a cooling band (or similar) to help keep your body temperature down

37 Tips for Managing Barriers cont d: Tone: Incorporate stretching Balance problems: Get the support you need (do seated exercise or hold onto external support for stability e.g. a rail)

38 Tips for Overcoming Lack of Motivation Find an activity you truly enjoy doing Find an exercise buddy/ check-ins with family and friends Small rewards Set achievable goals for yourself Don t get discouraged

39 Tips for Addressing Financial Barriers and Transportation YouTube.com search: It s Your Choice MS exercises "Cara Kircher" for gentle yoga and Tai Chi T.I.M.E. Program UHN.ca website search: T.I.M.E. for locations Local community centres Check your local MS Society Chapter website for other group classes in your area Home exercise program; consult a Physiotherapist

40 Four main sections: Warm up (13 min) Main component: strength, balance and aerobic exercises (24 min) Hoola hoops (12 min) Mat exercises (15 min) Cool down (8 min) Three different levels- choose the most appropriate person to follow

41 Self Reflection Exercise Why is exercising important to me? Improved strength Better mobility More flexible Better mood Sleep better Fight diseases better Improved memory Slowed aging Better immune function Greater bone density Healthier joints More energy Stronger heart Easier breathing More balanced blood sugar Better balance Lower blood pressure Easier to do daily life activities Cope better with stress Feel more confidence Weight management Adapted from Motivating People to be Physically Active

42 Self Reflection Exercise What is the impact of inactivity on my life? Less strength Poor mobility Higher blood pressure Low mood Sleep problems Getting sick more often Loss of bone density Stiff joints More risk of heart disease Fatigue Less lung capacity More risk of diabetes Poor balance Less flexible Harder to do daily life activities More risk of stroke More risk of injury More vulnerable to stress Increased pain Weight changes More risk of dementia Adapted from Motivating People to be Physically Active

43 Making a Lifestyle Change Think about previous lifestyle changes you ve made What helped you make and maintain those changes? Can you use a similar strategy with respect to exercise and physical activity? Adapted from Motivating People to be Physically Active

44 Setting Activity Goals WHAT exactly are you going to do? HOW are you going to do it? WHEN are you going to do this? WHERE are you going to do this? FREQUENCY: how often are you going to do this? BARRIERS and SOLUTIONS are there any obstacles that may prevent you from following this plan?

45 When can a Physiotherapist Help? Recent change in function or relapse Frequent falls or fear of falling when exercising Advice and guidance for adapted exercise and/or individualized exercise prescription Rehabilitation for MS-related physical challenges (e.g. gait or balance impairments) or for an injury (e.g. sprained ankle)

46 Exercise: Find a safe, appropriately challenging and enjoyable way to keep moving

47 References Caspersen, C.J., Powell, K.E., Christenson, G.M. (1985). Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Reports, 100(2): Dalgas, U., Stenager, E., Jakobsen, J., Petersen, T., Hansen, H.J., Knudsen, C., Overgaard, K., Ingemann- Hansen, T. (2009). Resistance training improves muscle strength and functional capacity in multiple sclerosis. Neurology, 73(18): Duff, W., Andrushko, J., Renshaw, D., Chilibeck, P., Farthing, J., Danielson, J., Evans, D. (2018). Impact of Pilates Exercise in Multiple Sclerosis A Randomized Controlled Trial. International Journal of MS Care, 20: Frohman, A.N., Okuda, D.T., Beh, S., Treadaway, K,. Mooi, C., Davis, S.L., Shah, A., Frohman, T.C., Frohman, E.M. (2015). Aquatic training in MS: neurotherapeutic impact upon quality of life. Annals of Clinical Translational Neurolology, 2(8): Flachenecker, P., Kümpfel, T., Kallmann, B., Gottschalk, M., Grauer, O., Rieckmann, P., Trenkwalder, C., Toyka, K.V. (2002). Fatigue in multiple sclerosis: A comparison of different rating scales and correlation to clinical parameters. Multiple Sclerosis, 8(6): Guner, S., Inanici, F. (2015). Yoga therapy and ambulatory multiple sclerosis Assessment of gait analysis parameters, fatigue and balance. Journal of Bodywork and Movement Therapies, 19(1): Halabchi, F., Alizadeh, Z., Sahraian, MA., Abolhasani, M. (2017). Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations. BMC Neurology, 17 : Kargarfard, M., Etemadifar, M., Baker, P., Mehrabi, M., Hayatbakhsh, R. (2012) Effect of aquatic exercise training on fatigue and health-related quality of life in patients with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 93(10): Kayes, N.M., McPherson, K.M., Schluter, P., Taylor, D., Leete, M., Kolt, G.S. (2001). Exploring the facilitators and barriers to engagement in physical activity for people with multiple sclerosis. Disability and Rehabilitation, 33(12): Kim, T.W., Sung, Y.H. (2017) Regular exercise promotes memory function and enhances hippocampal neuroplasticity in experimental autoimmune encephalomyelitis mice. Neuroscience, 346:

48 References cont'd Latimer-Cheung, A.E., Martin, Ginis, K.A., Hicks, A.L., Motl, R.W., Pilutti, L.A., Duggan, M., Wheeler, G., Persad, R., Smith, K.M. (2013). Development of evidence-informed physical activity guidelines for adults with Multiple Sclerosis. Archives of physical medicine and rehabilitation, 94: Latimer-Cheung, A.E., Pilutti, L.A., Hicks, A.L., Martin Ginis, K.A., Fenuta, A.M., MacKibbon, K.A., Motl, R.W. (2013). Effects of exercise training on fitness, mobility, fatigue, and health related qualify of life among adults with multiple sclerosis: A systematic review to inform guideline development. Archives of Physical Medicine and Rehabilitation, 94: Marcus, B.H., Forsyth, L.H. (2009). Motivating people to be physically active. USA: Human Kinetics Mostert, S., Kesselring, J. (2002). Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis. Multiple Sclerosia, 8: Motl, R.W., Pilutti, L.A. (2012). The benefits of exercise training in multiple sclerosis. Neurology 8: Petajan, J.H., Gappmaier, E., White, A.T., Spencer, M.K., Mino, L., Hicks, R.W. (1996). Impact of aerobic training on fitness and quality of life multiple sclerosis. Annals of Neurology, 39(4): Pilutti, L., Platta, M.E., Motl, R.W., Latimer-Cheung, A.E. (2014). The safety of exercise training in multiple sclerosis: A systematic review. Journal of the Neurological Sciences, 343: 3-7. Salem, Y., Scott, A.H., Karpatkin, H., Concert, G., Haller, L., Kaminsky E. (2011). Community-based aquatic programme for individuals with multiple sclerosis: a pilot study. Disability and Rehabilitation, 33(9): Wens, I., Keytsman, C., Deckx, N., Cools, N., Dalgas, U., Eijnde, B.O. (2016). Brain derived neurotrophic factor in multiple sclerosis: effect of 24 weeks endurance and resistance training. European Journal of Neurology, 23 (6): Zou, L., Wang, H., Xiao, Z., Fang, Q., Zhang, M., Li, T., Du, G., Liu, Y. (2017). Tai chi for health benefits in patients with Multiple Sclerosis: A systematic review. PLoS ONE, 12(2): e